International Journal of Nursing

June 2020, Vol. 7, No. 1, pp. 69-77

ISSN 2373-7662 (Print) 2373-7670 (Online)
Copyright © The Author(s). All Rights Reserved.
Published by American Research Institute for Policy Development
DOI: 10.15640/ijn.v7n1a8
URL: https://doi.org/DOI: 10.15640/ijn.v7n1a8

Investigation of Nurses’ Mental Status during Covid-19 Outbreak - A Systematic Review

Pappa Despoina1 & Dafogianni Chrysoula2

Abstract
BACKGROUND: Coronavirus disease 2019 (COVID-19) appeared unexpectedly as an epidemic outbreak
from Wuhan city, in China. It was spread quite fast globally, raising governments’ awareness about possible
public health threat leading many countries to take restrictive measures in order to protect their citizens.
Nursing staff is among frontline healthcare workers that are exposed daily in such cases providing care to
patients by all means. AIM: This review aims to investigate the psychological impact of this outbreak on
nurses working under high-demanding situations. METHOD: The design of this study was about a
systematic research review. Search procedure was based on specific databases using keywords for nurses
and the COVID-19 pandemic. RESULTS: 41 reports of original researches were found after criteria
justification and databases search. Studies with nursing population and time limitation from December
2019 to March 2020 along with the presentation of COVID-19 outbreak were included. Finally, 6 reports
were included in this review. CONCLUSION: Reporting severe symptoms of anxiety, fear, depression
and many other negative emotions, it is urgent for hospital administrations to apply efficient measures for
nurses to empower their mental health status during COVID-19 pandemic.
Key words: nurses; COVID-19; Coronavirus 2019;
1. Introduction
It was December, 2019, as the first incidents of unexplained pneumonia appeared in Hubei Province, Wuhan, in
China. The local medical community was alarmed due to significant findings that revealed the human-to-human
transmission, without knowing the exact initial cause. According to epidemiological updates, this pneumonia has
begun to spread on not only locally but also in remote areas too. The World Health Organization (WHO, 2020)
has named this pneumonia-related disease as Coronavirus Disease 2019 (COVID-19) and soon received serious
attention due to rising incidence in Chinese mainland. The spread of the Coronavirus-19 was begun within a
month by reporting cases in neighboring countries and individually in Europe and America. As of March 26, 2020,
China had 81,285 total cases, while worldwide there were 462,684 cases recorded and 20,834 deaths (WHOa,
2020). What is impressive, however, is the fact that some European countries, such as Italy and Spain, had
extremely high virus transmission speeds, with a significantly higher incidence of deaths than China. In the case of
Italy, this may be due to the aging population, but also the need of the government to take restrictive measures
earlier. This situation leads the hospitals’ staff to catch up with a difficult and quite stressful reality. The frontline
medical staff of the countries involved has to manage patients with COVID-19 symptoms, such as fever, dry
cough, fatigue, headaches etc. (Huang et al., 2020) using WHO guidelines and national competent authorities, at a
time when there is no clear and documented medical treatment of such incidents. In addition to clinical trials of
possible treatments, which require a specific period of time for their approval, staff is at risk of contagion, as there
are records of health professionals’ illness, but also in continuous worry about the future of this pandemic. Similar
events have happened several years ago, awakening memories of the SARS pandemic, for example, which has
caused not only human losses but also raised significant worries, phobias and strong emotions to other people
(Chiu et al., 2003; Leung & Ooi, 2003). Thus, it is very possible that the prolonged feeling of agony, serious
depressive tendencies, post-traumatic stress, and even suicide are likely to be developed in the global community.
Nurses are always in the forefront of any dangerous medical situation, like infections and it should be given
special attendance to this part of staff.
1.1. Nurses in front of an outbreak
It is well known that humanity faced several health threats some years ago. Ebola virus disease, in 2018,
H1N1 flu, in 2009, SARS epidemic, in 2003 and many more diseases in the previous years killed thousands of
people in many countries.

1 RN, MSc, PhD(c), Hygeia Hospital of Athens, University of West Attica, Greece
2 RN, BSc, MSc, PhD, Associate Professor, Department of Nursing, University of West Attica, Greece
 70 International Journal of Nursing, Vol. 7, No. 1, June 2020

Each virus affected differently the individuals causing devastating complications. Coronavirus disease is
the new threat for global public health and especially for each country’s health system. It can be transmitted
through air droplets, contact and aerosols (Special Expert Group for Control of the Epidemic of Novel
Coronavirus Pneumonia of the Chinese Preventive Medicine, 2020). On January 30, 2020, WHO announced
COVID-19 as a global public health emergency and two months later, approximately, on March 11, called it
pandemic. Such situations threaten not only physical status but also the mental health of people. Constant worries
and fears can be presented among individuals and everyone can perceive this reality in a different way (Khalid et
al., 2016). Fear could be the worst ally for someone and as Zhong Nanshan stated, psychological fear can be more
fearful than the disease itself (Liu, 2003). Due to the rapid spread of Coronavirus, medical teams were given
guidelines to deal with patients who appear to have the specific COVID-19 symptoms. The number of patients
was excessive and unbearable for some hospitals. The increasing need for acute and intensive care was a fact along
with the staff and equipment shortness. Healthcare workers must provide patient care but they have to protect
themselves too (American Nurses Association, 2020). Working in situations of crisis can cause overwhelming
psychological pressure to nursing staff. Nurses stand next to the patients much more time than other health
professionals, coping with the direct and threatened needs of them. Wong et al. (2005) stated in their study that
nurses came up with much more pain than doctors during Ebola outbreak. Several studies revealed that nurses
who face the possibility of contagion of them (Liao et al., 2017; Askim et al., 2018; Nayeri et al., 2019) and their
families experience high levels of stress, depression symptoms, resignation and stigmatization. After the case of
SARS, many reports mentioned the emotional impact on caring of contagious people, promoting the development
of nursing care models and assessing the care provided (Watson, 2009). Of course, mental health of health care
workers will be influenced by pressing conditions and it is easy to understand that psychological support to nurses
could contribute to better job performance (National Health Commission, 2013). In 1996, Saakvitne and
Pearlman used for the first time the term vicarious traumatization and in 2020, Li & colleagues combine it with
the COVID-19 outbreak. This term refers to an unwilling connection of the health professional with his patient
due to prolonged exposure to his/her disease. More specific, the researchers connected vicarious traumatization
with medical staff and general public. Frontline nurses seem to experience in some extend vicarious
traumatization during Covid-19 exposure but non-frontline nurses have higher severity of this condition and it is
more likely to experience psychological problems. As COVID-19 continues spreading across the world, public
health experts emphasize on healthcare and hospital resources urgent need (Jiang e t al., 2020; Pan et al., 2020). As
always, nurses form a big staff part in hospital and play a significant key role not only by preventing contagion
among others but also providing advice and education to non-professionals. Nursing in community, outpatient
and acute care settings is a risk throughout providing care. Nurses have to protect themselves and follow the
guidance of the Centers for Disease Control and Prevention (CDC, 2020) or other official health agencies. They
will always be at the frontline caring for the patient, assuring that he or she receives the best quality of care and
assessing each time the possibility of increased care need. The worldwide pandemic requires nurses’ cooperation
towards clinical care, education and shape of a public health policy that they will have to share and promote.
World Health Assembly has designated 2020 the International Year of Nurse and the Midwife (ICN, 2019).
Through this pandemic crisis, all nurses must constantly prove their importance, necessity and value within a
holistic health care system aiming to enhance Nursing profession.
2. Aim
This systematic review aims to explore the psychological impact of the COVID-19 outbreak on nurses’ mental
health, who work under difficult situations trying to provide best care to their patients. Because of the sudden
appearance and fast spread of this virus, the review is based on a short period limitation and had two specific
aims:
1. To investigate the nursing studies that took place due to this outbreak and synthesize a summary of them.
2. To present the search results so as to sensitize health agencies towards possible psychological needs of nurses
working with COVID-19 patients.
3. Method
According to the guidance of Kitcenham & Bacca (2004) methodology, we, firstly, organized the plan of
this systematic review which was to deal with a nursing issue on a well timed topic to provide important data for
evaluation and sensitization of the health professional population. After that, we conducted a search strategy
which had to do about the inclusion criteria of the studies, the time limitation and the type of the reports. The last
step was to present all the appropriate studies that could help in understanding the influence of COVID-19 in
nursing population’s mental status.
In this research procedure, we used academic databases such as Medline through Pubmed and one
academic research engine (Google Scholar), due to important findings for this topic that were not appeared in the
Pappa Despoina & Dafogianni Chrysoula 71

previous two databases (Pubmed/Medline). So, we considered that every scientific finding should be included at
this time. Initially, we used keywords like nurses; AND mental health; AND covid-19; AND anxiety; but the
search results were very few. So, we widened the outcome by using the words nurses; AND covid-19;. By this
time, on March 27, 2020 we came up with forty-one items from Pubmed and three from Google Scholar search
engine. Time limitation was a three-month period that Covid-19 exists globally and the studies included herein
were about nurses only.
3.1. Search outcome
The results of the research are shown in Table 1. A total of forty-four reports were found using the specific
keywords. As mentioned above, forty-one items came from Pubmed, Medline database and three from Google
Scholar search.
Table 1. Electronic databases searched and number of results.
Database Papers identified
Medline (through PubMed) 41
Google Scholar (academic research) 3
Total 44

A flow diagram illustrates the search and screening process and can be viewed in Fig.1. From the total
number of surveys, we examined the titles and abstracts to check the relevance of the content to the subject of the
review. Three out of the forty-four surveys found via pubmed database, were completely relevant to the topic.
There were two editorials and one correspondence article that contained important information on the practice of
clinical nursing in pandemic situations, but could not be included in this review. Finally, three more studies were
included in this search, out of pubmed database.

44 items identified through

Pubmed/Medline and Google
Scholar search
(n=44)

44 items were screened

by title/abstract

35 items were removed

after title/abstract screening

9 items screened
by full text for eligibility

3 items were removed

after full text screening

6 items were included in

the final review

Figure 1: Flow chart documenting the selection process

72 International Journal of Nursing, Vol. 7, No. 1, June 2020

4. Results
The main findings are oriented towards the mental status of nurses working in hospital with COVID-19
patients. All of the studies took place in Chinese hospitals because Wuhan city, in China was the epicenter of the
pandemic and by this time, there has been quite reasonable time to organize and accomplish a research study with
a sample of medical staff population. Lai et al. (2020) conducted a survey about the factors associated with mental
health outcomes of health care professionals working with coronavirus-19 patients. 764 out of 1257 individuals
were nurses working, some of them, in Wuhan and in frontline settings. According to their findings, nurses,
female medical workers and frontline professionals experienced symptoms of depression, anxiety, distress and
insomnia in a severe degree than other staff. 7,1% of nurses stated severe depression vs. physicians (4,9%). Severe
insomnia was found in 1,7% of the total frontline workers. A significant finding in this section was that second-
line workers were found to experience severe depression symptoms than those in front-line. Health care workers
were especially measured by senior, intermediate or junior technical title. The existence of an intermediate
professional title of health workers was associated with severe symptoms of depression, anxiety and distress. Most
of the nurses had a junior title (n=546), 191 of the total nursing sample were intermediate and 27 were senior
nurses. Researchers completed their survey by stating that providing front-line health care composes an
independent risk factor for unpleasant mental health outcomes of people who endanger their integrity through
COVID-19 pandemic. In another study, Liu and colleagues (2020) investigated the mental health status of 1853
doctors and 2826 nurses aiming to identify the key population of psychological intervention. They collected
questionnaires from 348 hospitals in mainland China within a week (17th to 24th, February). Most of the sample
were females (82,3%) and 57,4% had bachelor’s degree. The average age of the participants was 35,9 ± 9 years
old. A total of 60,7% of the sample had no mental health problem and approximately 9% appeared with anxiety,
depression and distress. Nurses appear to have psychological distress, anxious symptoms and depression signs in
15,3%, 17,6% and 39,2% respectively and quite higher from doctors’ percentages. Both doctors and nurses from
high-risk departments mentioned in higher prevalence of the above three mental problems.
Distress and anxiety appeared in health care professionals who had treating contact with COVID-19
patients along with 37,2% with depressive symptoms. It is important to mention that 35,7% of the sample had
received psychological counseling or intervention some time before the outbreak. Last but not least, the mental
health status of nurses could be influenced by the psychological condition of patients due to prolonged nearby
stay of nurse to them. Huang, Xu and Liu (2020) investigated a few days before the previous study the emotional
responses of nurses and nursing college nurses during COVID-19 outbreak along with the coping strategies. A
total of 802 valid and complete questionnaires were included. 374 nurses and 430 nursing students were the two
basic parts of the study population. Nurses and students from rural and urban cities, males and females, cities
from different epidemic levels participated in this survey. Researchers used a 5-point scale for nurses and students
experiencing anxiety, fear, sadness and anger during Coronavirus-19 outbreak. They also used BriefCope tool to
measure coping strategies in this specific period of time. This tool is based on problem-focused and emotional-
focused of participants coping to report how often they apply one out of two strategies in each project at the time
of outbreak. According to their findings, nurses experience anxiety (t(799,33)=3.05, p=0.002), fear (t(799,33)=3.05),
sadness (p=0.000) and anger (t(802)=4.56, p=0.002) in significantly higher levels than nursing students. Women
participants had also higher levels of anxiety (t(802)= -3.62) and fear (t(314,44)= 5.17) than men. Testing one-way
ANOVAs due to severity examination of COVID-19 in the city for each emotion, no significant differences
found. However, significant difference was found after multiple comparisons of anxiety and space distance of
Coronavirus-19 patients. Anxiety in near space distance found to be greater than far space (p=0.000). The same
(p=0.000) was found for anger emotion and near distance too. In terms of coping strategy nurses use quite more
often problem-focused coping methods (active coping, planning, and use of instrumental support) than nursing
students, as females do too. Several correlations have been made among each four emotions and coping strategies
after controlling identity, spatial distance, gender and rural-urban relationship. These four emotions were
positively correlated with problems and emotion-focused coping (ps<0.001). In another one cross-sectional
survey from China (Zhu et al., 2020), in which 79 doctors and 86 nurses participated, researchers studied the
prevalence and influencing factors of anxiety and depression in the first line medical staff during Covid-19.
Clinicians completed three questionnaires: self-rate anxiety scale (SAS), self-rate depression scale (SDS) and the
Simplified coping style questionnaire (SCSQ). 24 out of 86 nurses (27,9%) were the prevalence rate for anxiety
and 37 out of 86 (43%) of depression. History of anxiety or depression was an independent risk factor in nurses.
However the study is based on a small size of healthcare staff, especially nurses, decreasing the reliability of the
research. Jizhen et al. (2020) conducted a survey on medical staff mental health in Covid-19 hospitals. Nurses
were found to have more anxiety than doctors (26,88%-43/160 vs. doctors 14,29%-10/70) with statistically
significant difference. Their results of nurses’ anxiety were slightly higher than Yuan Yuan’s et al. (2019) who
correlated anxiety and depression status of medical staff. Vicarious traumatization is a term recently connected
with healthcare workers during Coronavirus-19 pandemic.
Pappa Despoina & Dafogianni Chrysoula 73

It was mentioned above and Li with colleagues (2020) accomplished a study about this phenomenon in
the general public, members and non members of medical teams aiding in Covid-19 control. The sample of this
study consists of 214 general public individuals and 526 nurses (234 front line nurses and 292 non-front line
members) to assess vicarious traumatization scores. Front-line nurses experience lower scores of vicarious
dramatization than general public and non-front-line nurses (64 FLNs vs. 75,5% GP vs. 75,5%nFLNs). 96 out of
234 front line nurses most of the participants work in critical care medicine and 142 of non-front-line nurses in
surgery departments. Also, most of the sample of nurses possesses a senior title. This study aimed to emphasize
that general public and non-front-line nurses had no significant difference in vicarious traumatization scores,
possibly due to strict Chinese policy to face Coronavirus-19 epidemic. This means that these two groups were
forced to avoid face-to-face contact and communication.
Author, year Design Aim of the Sample Mental Findings
& country study health
measure
Li et al., Descriptive To evaluate 740 total (214 Mobile app of Frontline
2020, China vicarious general a 38-item nurses appear
traumatization public, 234 questionnaire (FLN) to have
scores in the front-line with lower
general nurses, and physiological vicarious
public, 292 non and traumatization
members and front-line psychological scores than
non-members nurses). responses. non frontline
of medical nurses.
teams. General
public scores
were higher
than FLN.
Lai et al., Cross- To assess the 1257 health 9-item-Patient A proportion
2020, China sectional, magnitude of care workers Health of health care
survey-based, mental health (764 of them Questionnaire, workers
region- outcomes and were nurses) 7-item- experienced
stratified related factors Generalized depression,
study among health Anxiety anxiety,
professionals Disorder insomnia, and
working with scale, 7-item- distress,
COVID-19 Insomnia especially
patients. Severity Index women and
and the 22- nurses and
item- Impact front-line
of Event workers.
Scale-Revised.
Jixuan et al., Cross- To investigate 246 front-line Self- The incidence
2020, China sectional the mental medical staff assessment of anxiety was
health status (nurses scale for higher in
of clinical included) anxiety (SAS) nurses than
front-line and self- that of
medical staff assessment doctors
during scale for post- (26,88% vs
COVID-19 traumatic 14,29%). The
outbreak. stress disorder stress score
(PTSD-SS). was higher in
female
medical staff.
Zhu et al., Cross- To 165 health SAS, self- The
2020, China sectional understand professionals rating prevalence
the prevalence (86 nurses) depression rate of anxiety
and scale (SDS) and
influencing and the depression
factors of simplified symptoms
74 International Journal of Nursing, Vol. 7, No. 1, June 2020

anxiety and coping style among nurses

depression in questionnaire was 27,9%
medical staff (SCSQ). and 43%.
during History of
COVID-19 in depression
Gansu. was a
common risk
factor.
Liu et al., WeChat- To investigate 4679 total SAS, Self- Being a nurse,
2020, China based survey the mental (2826 nurses) reporting Working at
health status Questionnaire high-risk
of health staff (SRQ-20), departments,
and to SDS treating
identify the patients with
key COVID-19
population pf had higher
psychological risk of
intervention. developing
distress,
anxiousness
and
depression.
Huang et Online To investigate 802 total (374 BriefCOPE Nurses
al., 2020, questionnaire the current nurses and tool, 5-point showed
China survey state of 430 college scale for higher levels
emotional nurses). anxious, fear, of anxiety
responses and anger and (P=0.002),
coping sadness. sadness
strategies of (t(799.33=4.59,
nurses and P=0.000).
college nurses Nursing
students college
during students had
COVID-19 stronger
emotional
responses and
more willing
to Problem-
focused
coping.
Table 2: Summary table of included papers
5. Discussion
Nurses are central to the management and controlling of the pandemic both in the hospital environment
and in the community. The provision of good-quality nursing (Shih et al., 2007; Chan, 2003; Tzeng, 2003) care in
such situations depends on the proper management of human and material resources (Chan-Yeung, 2004) in
hospitals but also on the health status of the nurses themselves, especially in psychological level. According to
several studies, both for the present Coronavirus pandemic and for previous ones (Nickell, 2004), the nursing
population experiences strong feelings of anxiety, depression and fear depending on different demographic data,
the distance they have from the facing and treatment of such patients, the perceived gravity of the matter etc. The
majority of the studies suggested that there are increased levels of anxiety in medical teams but nurses, specifically,
seem to experience anxious or depressive symptoms in higher percentages than doctors and general public (Li et
al., 2020; Liu et al., 2020) . This is explained by the prolonged stay of the nurse in wards due to treatment
continuity or the direct exposure to such patients in acute care settings. Female gender and nurses with an
intermediate technical title appear to have severe anxiety, depression and distress for this pandemic situation. In
SARS outbreak, psychological distress was reported too. 42000 health care professionals work in Wuhan and 68%
of them are nurses (National Health Commission, 2020). Researches indicate that high priority in total support
should be given to this part of staff (Liu et al., 2020).
Pappa Despoina & Dafogianni Chrysoula 75

Findings from the same study emphasize, also, in possible previous psychological help to medical staff
implicating the targeted attention which must be given. A very important key population is the front-line nurses
who undertake unintentionally not only the management of an infectious patient but also the education of the
suspected cases and patients in community towards better understanding of the pandemic situation by clearing up
at the same time the fact of the misinformation provided by different means (Wen et al., 2020). Nursing
individuals experience differently a psychological crisis. A study between nurses and nursing students during
COVID-19 outbreak (Huang et al., 2020) showed the high prevalence rate of anxiety, fear, sadness and anger of
nurses associated with students. It is easy to understand that nurses who have much more experience, knowledge
and frequent contact with patients may perceive in a better way the real danger from an epidemic outbreak than
nursing students. However, this was a quite useful approach in order to sensitize the students towards careful
nursing care using the protection measures when needed and realize the importance of nurses’ role to the medical
team and the health system, in general. Being a nurse at the core of infection risk causes concern about being
infected too, worry about nurses’ family infection danger, possible isolation policy, working conditions (Chan-
Yeung, 2004) and sadness towards suffering and even death, quite often, of critically ill patients (Huang et al.,
2020). These situations can lead the health professional to develop self-defeat, self-blame and emotions of guilt
and failure. It is not easy to fight against an infectious pandemic. Luckily, there are many nurses who experience
this situation as stimuli for professional responsibility and altruism (Maunder et al., 2003). A strong mental status
is required in order to adopt an effective coping strategy during a pandemic. Problem-focused and emotional-
focused coping strategies are recorded through studies. Nurses seem to use mostly the problem-focused strategy
(Huang et al., 2020) owing to having more experience to similar pressures. Last but not least, it is the attitude of
patients itself that can have a serious impact on nurses’ resilience towards these situations. When a patient does
not want to cooperate with the treatment because of his temper or fear of his own life threatening, nurses have to
make greater efforts to persuade him keeping up with instructions (Chen et al., 2020). The picture of a powerless
and sometimes a hopeless patient for a prolonged time creates a psychological threat for nurses. Health
institutions must provide psychological skills training to strengthen nurses’ ability to endure such pressures and
manage them efficiently (Chen et al., 2020; Li et al., 2018).
6. Conclusion
Nurses have been, and will continue to be, the frontline professionals in treating patients not only
through their direct contact within acute care departments but also for their 24-hour stay next to the patients,
treating them in nursing institutions or in the community. It is agreed that it is the duty of the nurse not only to
provide the best health care, with all the necessary and appropriate means, but also to prevent situations which
would incommode and expose the individual to danger and risk overall public health. Apart from nurses’
obligations, we must accept that nurse is a human being too. This person has his own personality, characteristics,
specific mental status and endurance. Ιn the practice of nursing, health institutions should investigate, organize,
implement and evaluate psychological support programs for all health professionals with the ultimate aim of
empowering and encouraging staff. Mental health of nursing population should be assessed by experts via
interviews and questionnaires following a typical procedure within hospitals. Assisting with additional staff and
specific absence days for employee could be an efficient measure for nurses to rest during a crisis. Through this
COVID-19 outbreak nurses are likely to develop fatigue, burnout, phobias and many more negative emotions due
to the ultimate fear of contagion and uncertainty of spread. Many more studies have to be done to contribute to
nursing society and show the need of measures upon an outbreak that have to be taken. Enhancing nurses’
resilience towards this pandemic is strongly needed so nurses can obtain greater level of mental health to deal with
infectious patients with a high risk of transmission to them and provide excellent care at all levels of health.

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